Palgrave Macmillan, 2014, 262 pages, $42.50 (hb)
Review by Phil Shannon
When Richard Ablin, then a young immunologist and now a University of Arizona pathology professor, discovered, in 1970, an enzyme specific to the prostate gland (prostate-specific antigen or PSA) whose elevated levels in blood indicate an abnormality in the gland, he had no idea how a simple blood test would go on to become the foundation of a “profit-driven public health disaster” through prostate cancer screening.
Elevated PSA levels can be caused by prostate cancer but also by infections, aspirin, riding a bicycle, ejaculation and normal, age-related prostate enlargement. The PSA test is organ-specific not cancer-specific yet it has become ubiquitous as a diagnostic cancer-detection tool leading to many unnecessary and dangerous treatments.
Most prostate cancers are slow-growing and can be safely left alone because prostate cancer is an older man’s disease and nearly all men will die with it but few of it, succumbing instead to other diseases of ageing (80% of men in their seventies will have prostate cancer but only 3% will die because of it). Nearly all prostate cancers will do absolutely no harm unlike, however, the screening and treatment for them.
Because of the PSA blood test’s worse-than-chance inaccuracy (15% of its negative results are wrong, 60-80% of its positive results are wrong), the test requires a follow-up biopsy of prostate tissue. The biopsy causes bleeding and pain and, with the biopsy needle passing through the bowel, carries a risk of potentially fatal infections of genito-urinary organs and of the blood.
The treatments that follow biopsy have their own suite of adverse effects. Surgical removal of the prostate gland (prostatectomy) carries a high risk of urinary incontinence and erectile dysfunction, radiation therapy causes inflammation of the bowel, and chemotherapy is not renowned for its pleasures.
The associated waste of health resources and men’s well-being is staggering. There are an annual 30 million PSA tests (at $80 a pop) in the US, a million biopsies (at $2,000 each) and 100,00 prostatectomies (each fetching $30,000) for a total cost of US$28 billion, coming from the pocket of patient or taxpayer. All of this expense is for little clinical benefit – one thousand men have to be PSA-tested to successfully prevent just one prostate cancer-related death.
Yet, the PSA test has become embedded in routine men’s health checks – all because of money, says Ablin. Entrepreneurial medical scientists and the biotechnology industry saw the potential of mass screening to turn the PSA test, and its more expensive successor blood tests and cancers treatments, into a cash-cow, to be milked by pathology, urology, radiotherapy and oncology practices, medical device companies and ancillary medical businesses (erectile restoration, incontinence pads).
From blood test to diaper, “the prostate cancer business is a self-perpetuating industry that creates a need for its services and products”. The only difference any of this over-servicing makes is to the corporate medical bottom line, not to prostate cancer mortality.
Corporate influence over government health watchdogs also creates a regulatory culture “that looks the other way” over dodgy data and clinical risk, whilst medical industries finance most clinical trials and dollar-dazzled doctors-for-hire have a financial interest in plugging the PSA test. The corporate dollar also feeds patient advocacy groups whilst marketing triumphs over evidence as charismatic survivor testimonials and sports celebrity endorsers manipulate millions of men, playing on the fear of cancer, onto the prostate cancer conveyor belt with its unnecessary, costly and dangerous, but above all, lucrative, testing and treatments.
“Powerful interests knowingly misused the PSA test to generate huge profits”, concludes Ablin. Be informed, is his warning to men when their GP talks prostate. Ablin’s story of “greed and damaged men and government failure” is a good place to start.